Advancements in robotic hysterectomy
Throughout the case, suction-irrigation and passing of suture are carried out by temporarily removing the robotic instrument in the 8-mm mediolateral port.
Single-site technique
Patient positioning, placement of the uterine manipulator, and insufflation are again all performed as described for the multisite technique.
The single-site port is placed via an approximately 2-cm incision (Omega, Arch or Z type) through the umbilicus with the arrow displayed on the port pointed toward the target organ. The single-site port accommodates insufflation tubing, an 8-mm camera, two 5-mm operative instruments, and an assistant instrument; all are placed through preordained, standardized lumens (see image 6).
The surgical cart is straight or side docked on the patient’s right side. The cannulas labeled "1" and "2" are docked to robotic arms "1" and "2."
The new single-site tool set differs from instrumentation used in multisite and dual-site procedures in that the operative instruments do not have articulating wrists. Instead, they are flexible and semirigid, allowing them to fit through the curved cannulas to facilitate operative triangulation.
The aesthetic umbilical port placement used in the single-site platform should allow the completion of hysterectomy in uteri with straightforward pathology up to approximately a 14-week size.
The lateral attachments are isolated, secured, and transected as previously described utilizing the 5-mm bipolar Maryland forceps and the 5-mm monopolar hook. Additional presentation and retraction of tissue are performed by the first assistant.
Development of the bladder flap and the anterior and posterior colpotomy are performed just as they are in the multisite and dual-site techniques. If needed, internal swapping of the bipolar and the hook may facilitate more precision during right- and left-side dissections.
Uterine arteries are also dissected in an identical fashion, with internal swapping of instruments facilitating a more precise right and left dissection if needed.
The vast majority of single-site hysterectomy specimens will be removed transvaginally intact. In the supracervical approach or with larger uteri, a transumbilical approach using traditional morcellation can be used. The robotic patient side cart is undocked, the single-site port is removed, and a retractor (the Mini Mobius retractor by CooperSurgical or the extra small Alexis retractor by Applied Medical in Rancho Santa Margarita, Calif.) is inserted.
The specimen is then removed utilizing traditional instruments (i.e., knife, tenaculum, Mayo scissors). Visual "in-line" endoscopic morcellation is not recommended.
The absence of articulating wrists does add some difficulty to the vaginal cuff closure when compared to the multisite platform. We found use of the 5-mm curved needle driver combined with a Keith needle to be highly effective and time efficient (see image 7). Throughout the procedure, suction and irrigation are performed with a 5-mm instrument and suture passage is carried out via the assistant port.
The new robotic single-site instrumentation maintains advantages compared with traditional laparoscopic instrumentation. High-definition three-dimensional visualization, tremor-free instrument movement and surgeon ergonomics are distinct advantages. Other benefits include curved cannulas that restore triangulation and software that reassigns the instruments visualized on the right and left sides to the right and left hands, making hand-eye orientation fluid and intuitive.
Dr. Payne reported that he is a member of the speakers’ bureau for both Intuitive Surgical and CooperSurgical. He would like to acknowledge Dr. Devin Garza, Dr. Sherry Neyman, and Dr. Christopher Seeker for their collaboration and contributions to development of the dual-site approach, and Dr. Garza, Dr. Neyman, and Dr. Lisa Jukes for their contributions to the single-site technique.
